Household wealth and HIV incidence over time, rural Uganda, 1994-2018

John S. Santelli, Ivy Chen, Fred Makumbi, Ying Wei, Fred Nalugoda, Tom Lutalo, Esther Spindler, Stephanie A. Grilo, Andrea Deisher, Katherine Grabowski, Susie Hoffman, Joseph Kagaayi, Larry W. Chang, Ronald Gray, Maria Wawer, David Serwadda

Research output: Contribution to journalArticlepeer-review


Objective:To examine the relationship between household wealth and HIV incidence in rural Uganda over time from 1994 to 2018. In research conducted early in the epidemic, greater wealth (i.e. higher socioeconomic status, SES) was associated with higher HIV prevalence in sub-Saharan Africa (SSA); this relationship reversed in some settings in later years.Design:Analysis of associations over time in a population-based open cohort of persons 15-49 years from 17 survey-rounds in 28 continuously followed communities of the Rakai Community Cohort Study (RCCS).Methods:The RCCS sample averaged 8622 individuals and 5387 households per round. Principal components analysis was used to create a nine-item asset-based measure of household wealth. Poisson regression with generalized estimating equation (GEE) and exchangeable correlation structure was used to estimate HIV incidence rate ratios (IRRs) by SES quartile, survey-round, sex, and age group.Results:From 1994 to 2018, SES rose considerably, and HIV incidence declined from 1.45 to 0.40 per 100 person-years (IRR = 0.39, 95% CI = 0.32 - 0.47, P < 0.001). HIV incidence was similar by SES category in the initial survey intervals (1994-1997); however, higher SES groups showed greater declines in HIV incidence over time. Multivariable analyses showed significant associations between HIV incidence and SES (IRR = 0.55 for highest compared with lowest quartile, 95% CI = 0.45 - 0.66, P < 0.001) controlling for time, sex, and age group.Conclusion:Beyond the early years of the RCCS, higher SES was associated with lower HIV incidence and SES gradients widened over time. The poor, like other key populations, should be targeted for HIV prevention, including treatment as prevention.

Original languageEnglish (US)
Pages (from-to)1835-1843
Number of pages9
Issue number11
StatePublished - Sep 1 2021


  • AIDS
  • HIV incidence
  • socioeconomic status
  • sub-Saharan Africa
  • wealth

ASJC Scopus subject areas

  • Immunology and Allergy
  • Immunology
  • Infectious Diseases


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